An extraction is the surgical removal of a tooth from the jaw.

This is done for a variety of reasons, and is a fairly common procedure in most General Dental offices across the country. Extractions range from "Simple" to "Surgical", with most being surgical. Simple Extractions are usually done for Orthodontic purposes, crowding purposes and some periodontal purposes.

Once the tooth is removed, the socket is cleaned and debrided. A medicine, Chlorhexidine, is used to irrigate the socket and provide a bacteriostatic environment, which is conducive to rapid healing. Dr. Hoffman will then place an antibiotic and bone grafting material into the socket, to allow bone regeneration to occur more completely and rapidly, this grafting process will also reduce post-operative discomfort significantly. Bone grafting allows the patient's bone to remain full, thick, and normal in appearance. This will facilitate better placement of a future implant, bridge, or better fit for a partial denture – all used to restore the area of the extracted tooth. No bone grafting is used in Orthodontic, or crowding, dental cases, as this delays the multidisciplinary care involved.

Extractions do not hurt while being performed, but the area may be slightly sore after the procedure is completed and the anesthesia has worn-off.

Usually, Dr. Hoffman prescribes a day-or-two of medication for discomfort, ensuring you sleep well during the night, and are comfortable during the day. Many times you are not allowed to drive on these various medications, so if you are in doubt, please ask. The level of discomfort most patients state is low, and only last 24-48 hours. On a scale of 0-10, with 0 being asleep, and 10 being the worst pain imaginable, most patients state their discomfort is between a 1-to-3.

There is usually a little blood seepage from the wound for the first 24-hours, so do not sleep on your best pillow covers the first night. Please remember, a little blood, mixed with a lot of saliva, looks like a lot of blood; however, it usually is very normal. Dr. Hoffman will not let you leave without achieving "hemostasis", which means all bleeding is under control and the patient is ready to manage his or her own care at home. Most patients will leave with gauze in place to keep pressure on the extraction site, as well as a possible ice pack, both to keep swelling to a minimum. Please do not forget to remove the gauze from your mouth if you are going to sleep or nap. A patient could potentially choke on that gauze while sleeping and potentially die. Do not forget this, as many patients go home "beat" from the adrenalin associated with the visit, being worried and such (although there is nothing to truly worry about). Please remove the gauze before you lay down to sleep.

Dr. Hoffman will call you the next day, usually in the morning, to see how you are feeling. Most patients feel "just fine" and are back to work, school, and living normally. It is best if heavy lifting is removed from daily living activities for the following 2-5 days, depending on the type of extraction. This is to ensure the clot remains in place and you do not develop alveolar osteitis (AKA: Dry Socket). This is a painful possibility, usually occurring 3-5 days after the procedure is completed. Most patients who smoke are at a greater risk of developing this painful phenomenon. Under normal conditions, will be seen by Dr. Hoffman 10-days after the procedure to remove the sutures and re-evaluate healing. At this time restrictions are relaxed significantly, to completely.

A bridge is prosthetic that replaces a missing tooth/teeth; it is permanently cemented to a tooth or teeth in front, and in back, of the missing tooth/teeth it is replacing.

A bridge looks like real teeth; in many cases it even looks better than the original teeth did before the bridge was placed. This is because it can be made to more ideal specifications, with regard to shade, shape, and function.

Bridges are placed by preparing the tooth/teeth in front of the missing tooth, or teeth, and preparing the tooth/teeth behind the missing tooth/teeth. These preparations are the same preparations that are done for single unit crowns. The only difference is these teeth must be prepared with a path a withdrawal and insertion; this is called parallelism. To decide how many natural teeth must be prepared to properly construct a bridge which will last the normal life expectancy, dentists follow a law of physics called Ante's Rule. It outlines how a structurally-sound bridge needs to be constructed.

Bridges are considered "permanent" restorations, in that they are cemented on the teeth and do not come in-and-out, but are permanently affixed.

The average lifespan of a high-quality, properly prepared and fabricated bridge is approximately 15-30 years. The better the doctor that prepares the teeth, and the better the laboratory that fabricates the bridge, the longer that bridge should last.

While bridges themselves do not get cavities, the interface between the bridge and the natural teeth on which the bridge rests (AKA: the margin) can get cavities, and is the primary area where cavities do form after bridges are placed. A patient can aid in increasing the lifespan of a bridge by brushing it 3x daily, and flossing under it and around it nightly. Many times a WaterPik is a desired adjunct to regular flossing, as it ensures a thorough cleaning under the pontics (AKA: fake teeth) of the bridge. Keeping your new bridge clean should be of primary importance.

Once the bridge is permanently cemented, it should be used as you would use all other teeth in your mouth, unless your dentist gives you other instructions. Today's bridges are made of all tooth-colored materials and most have no metal. Here at Hoffman Dental, Dr. Brian Hoffman does not use any metal in his crowns, bridges, inlays, onlays, or fillings. The substructure of bridges is primarily zirconia (AKA: man-made diamond material), or alumina. These materials have hardness strengths of 400-600 MPa for alumina based cores, and Zirconia based cores have strengths ranging from 900-1200 MPa. This is exceedingly strong and durable, plus they better mimic the metamerism (AKA: natural look and luster) of natural teeth.

An implant is a bone screw; constructed from titanium and many times coated via plasma spraying, anodizing, etching, or sandblasting to increase the surface area and osseointegration potential of the implant to the jawbone, on an electron-microscopic level.

Basically stated, it is conjoined with your own bone and the strongest microscopes we have, cannot tell a separation from the implant to your bone. Summarily, it is now a part of your body.

Implants look, feel, and act most like a natural tooth. They are considered the "Gold Standard" in permanent intraoral restorations, in most cases. Implants usually last the longest of all other dental restorations; however, from placement to final cementation of the implant crown – they are also the longest to complete. Many times it may take upwards of 6-months to complete the entire process and have a fully-functional tooth. This is due to the surrounding bony environment and circumstances about why a tooth, or teeth, became missing in the first place. There are yet other times an implant can be taken to completion in weeks. Much of that variable timeline is dependent upon the individual's unique and personal circumstances. The only way to know for sure how long it will take to complete your entire implant procedure is to talk to Dr. Hoffman and/or Dr. Evans about your particular circumstances.

As far as cost is concerned, a single implant is about the same price as a 3-unit bridge.

However, insurance companies many times do not cover the costs of the implant, but will cover the costs of the bridge. As insurance companies continue to lag behind in this area, it is hopeful as time progresses, insurance companies will realize this is a money-saving issue for them to get behind fully. In the meantime, the only way to know for sure is to ask your dental insurance company, or talk to Dr. Hoffman about your interests. Many times we will do this leg-work for you, as a courtesy, and report our finding to you.

The level of discomfort with an implant is extremely low. Most patients state it was less discomfort that having a tooth extracted. This is due to the aseptic and surgical nature of the implant placement process. Every aspect of the procedure is completely controlled and measured extensively, in multiple ways, before the first drop of anesthesia is placed to begin the actual implant placement. A typical implant placement surgery lasts about 2-hours, some lasting longer. Most times patients will be given medicine to make them sedated and relaxed, in fact, often patients fall asleep during the procedure. If you opt for these medicines, please ensure you have a driver (not a taxi) from door-to-door, as you will not be allowed to drive while on these medicines.

A denture is a full prosthetic replacement of an entire jaw's teeth.

It replaces all teeth in either an upper or lower jaw. Many times, patients have full upper and lower dentures, replacing all teeth in the mouth. These full dentures are removable, and are to be removed and cleaned after each meal and before bedtime. Full dentures are not to be worn while sleeping, as this habit will most probably lead to a fungal infection of the mouth.

Properly fitting dentures require multiple visits. The first visit it to gather accurate "impressions" and a bite registration of your mouth. These impressions are used to create an acrylic or metal base that is custom made to your current oral anatomy. Those will come back to the dental lab with wax on them. That "wax-rim try-in" will be the second visit. Here Dr. Hoffman will address your basic speech and verify a proper Vertical Dimension of Occlusion (VDO), together with proper bite relationship. The patient and dental assistant will also choose the proper shade, and shape of the denture teeth that will be used to make your final denture. On the third visit, the teeth you selected will have been placed into the wax-rim, creating an exact wax model of your proposed denture(s). This is called the "wax-tooth try-in". This will be tried in to your mouth for proper fit and speech requirements, as well as patient visual satisfaction. How do they feel, work and look? If Dr. Hoffman and you are both happy with all aspects at this stage, they will sent back to the lab to be finalized. Your fourth, and final visit, will be the "delivery" of your new denture(s). Again, if there are any minor adjustments, they are made at this time.

Dentures are usually not a patient's first choice for a final treatment option.

Many times there are financial reasons this option is chosen. There are other options, and if you already have a full upper and/or lower denture, there are ways to make that existing denture fit more reliably and remain more stable when talking and chewing. Please discuss this issue with Dr. Hoffman and his staff, if you are interested in options to help in this regard.

Most of the time, dentures should fit properly without the need of pastes and wafers. In some cases, the bone has been lost to a large degree, and the patient chooses not to do bone grafting to address these issues. In those cases, pastes and wafers may be necessary to add retention to the upper and/or lower denture. If you have an existing denture, and you remember the denture fitting much better in the past, but now it moves around a lot and you rely on the pastes and wafer to hold it in, you may be a candidate for a relinement of your existing denture(s). This procedure is usually fairly fast, and most times you will leave with your newly fitting denture the same day. In some cases, the denture is worn beyond repair and a new denture would then be recommended.

A partial denture is a partial prosthetic replacement of one, but usually many, of the jaw's teeth.

It is fabricated with a cast metal substructure, and sometimes a thermoplastic substructure, depending on the individual case. I t can be used for replacement of upper and/or lower teeth. Most patients who elect partial denture(s) are missing more than a-tooth-or-two, as there is a considerable amount of metal necessary in the mouth to properly support the partial(s). Usually, there are other options with partial denture(s), like bridge(s) and/or implant(s). Partial dentures are removable, and are to be removed and cleaned after each meal and before bedtime. Partial dentures are not to be worn while sleeping, as this habit will most probably lead to a fungal infection of the mouth.

Properly fitting partial dentures require multiple visits.

The first visit it to gather accurate "impressions" and a bite registration of your mouth. These impressions are used to create an thermoplastic or metal base that is custom made to your current oral anatomy. Those will come back to the dental lab with wax on them. That "wax try-in" will be the second visit. Here Dr. Hoffman will address your basic speech and verify a proper Vertical Dimension of Occlusion (VDO), together with proper bite relationship. The patient and dental assistant will also choose the proper shade, and shape of the denture teeth that will be used to make your final partial denture. On the third visit, the teeth you selected will have been placed into the wax, creating an exact wax model of your proposed partial denture(s). This is called the "wax-tooth try-in". This will be tried in to your mouth for proper fit and speech requirements, as well as patient visual satisfaction. How do they feel, work and look? If Dr. Hoffman and you are both happy with all aspects at this stage, they will sent back to the lab to be finalized. Your fourth, and final visit, will be the "delivery" of your new partial denture(s). Again, if there are any minor adjustments, they are made at this time.

Partial dentures are usually not a patient's first choice for a final treatment option. Many times there are financial reasons this option is chosen. There are other options, and if you already have an upper partial, or lower partial denture, there are ways to make that existing partial denture fit more reliably and remain more stable when talking and chewing. Please discuss this issue with Dr. Hoffman and his staff, if you are interested in options to help in this regard.

Partial dentures do not need paste or wafers for them to fit, as they use natural teeth as retention in the mouth. Often, over time, partial dentures will become loose; this may, or may not be correctable. If it is correctable, many times it can be corrected in the same visit it is evaluated, sometimes it does require a trip to the dental laboratory for clasp replacement or adjustment.

A veneer is a thin layer of stacked porcelain that covers the facial portion of a tooth/teeth, to give it/them the appearance of non-restored and ideally shaped and colored tooth/teeth.

Veneers can make an otherwise unattractive smile, look amazing. Veneers can correct spacing and crowding issues, they can change the color of teeth dramatically, and they can also lengthen or shorten teeth, as well as widen or narrow teeth. Overall, they can change a complete, but lackluster, smile into something you would see in a fashion magazine.

All the above said, veneers are not for everyone! Some people do not qualify for veneers and would be better-off to consider other options for smile restoration, or smile rejuvenation. If you may be interested in the possibility of veneers, consult Dr. Hoffman and see if this is an option for you. Other options would be crowns or bridges and possibly implants.

Veneers are considered permanent restorations, as they are bonded to your teeth and are not removable, unless they are removed by your Dentist.

Veneers are very hard, harder than you natural teeth actually. Veneers should be flossed, brushed, "WaterPik'ed" and everything else you would do to natural teeth to keep them clean and healthy. Veneers cannot get cavities, but the interface between the veneer and your natural tooth can get cavities. Because of this fact, it is suggested you care for them as diligently as you would every other tooth in your mouth, maybe just a bit more.

Veneers can be made in many ways; they can wrap around the edges of your teeth making them look very real, from every angle. They also can be made like contact lenses, meaning ultra-thin and basically prepless...hardly any tooth structure need be removed...and are just cemented to the front of your teeth. Again, it depends on the individual case and what your wants and needs are, versus what the intraoral condition dictates as possible options.

Veneers are often considered "cosmetic" in nature, and in many cases dental insurance will not cover their placement. In some cases, where the teeth have been heavily restored previously, or have cavities that necessitate a more comprehensive-type of restoration, veneers may indeed be covered by dental insurance. The only way to know for sure is to ask your dental insurance company, or talk to Dr. Hoffman about your interests. Many times we will do this leg-work for you, as a courtesy, and report our findings to you.

An inlay is a laboratory fabricated prosthetic that fits inside a tooth, looking much like a puzzle piece; inlays should last as long as a crown, when properly placed and cared for, also looking exactly like a natural tooth when completed.

There is no metal in todays inlays, as the zirconia, alumina and pressed porcelain is very strong and mimics the look of your existing teeth.

Inlays are used when a filling is going to be too large, causing the potential for fracture. Inlays are also used if a patient does not want to replace a larger filling as often, as inlays are made with a more durable material and are bonded to the tooth for a long service life. When inlays are done properly, and with proper continued homecare that includes daily brushing and flossing, an inlay should last 15-30 years.

Inlays look exactly like real teeth, in many cases even better, as they look like they are brand new teeth; all a single color with perfect cusps, fossae and contours. Inlays can close spaces between teeth, where food gets impacted, they can also restore a brighter smile to mouths that have large amalgam (AKA: mercury) fillings.

Inlays are precision oriented; precision takes a bit of time, so expect your appointment to not be rushed and be done correctly the first time. Dr. Hoffman is a perfectionist when it comes to creating the proper inlay preparation.

This is because part of making an inlay look and feel correct involves a dental laboratory, who performs their work based on principles of material science. Inlay preparations must have certain reductions and shapes (AKA: Internal Morphology) in certain specific locations, which allow the materials to possess the proper strength to last the full life-expectancy, also for the shade and shape of the inlay to properly mimic a natural tooth.

Inlays do not get cavities, but the margin, or area where the inlay meets the tooth can get cavities. Actually, this area is the area that most commonly fails on an inlay tooth. There are two ways to combat this phenomenon: 1. Have the inlay fit correctly at the time of placement 2. Make sure proper flossing and brushing is done around the inlay nightly.

Inlays take 2 visits to complete. The first visit is the actual removal of the damage and/or cavities and the preparation of the tooth for the inlay. This is also where the impression is taken for the lab, and when your temporary inlay is fabricated. The second visit is to permanently deliver your new inlay; this visit only takes about 30-minutes or so. Before your new inlay is permanently delivered to you, all parties must be completely happy. You must be happy with the color (shade), shape and bite, and Dr. Hoffman must be happy with the x-ray, the margins, the interproximal contacts, and the bite. Once everyone thinks things are "perfect", Dr. Hoffman will ask your permission to permanently deliver your new inlay.

An onlay is a laboratory fabricated prosthetic that fits inside and over a portion of a tooth, looking much like a puzzle piece; onlays should last as long as a crown, when properly placed and cared for, also looking exactly like a natural tooth when completed.

There is no metal in today's onlays, as the zirconia, alumina and pressed porcelain is very strong and mimics the look of your existing teeth.

Onlays are used when a filling is going to be too large, causing the potential for fracture. Onlays are also used if a patient does not want to replace a larger filling as often, as onlays are made with a more durable material and are bonded to the tooth for a long service life. When onlays are done properly, and with proper continued homecare that includes daily brushing and flossing, an onlay should last 15-30 years.

Onlays look exactly like real teeth, in many cases even better, as they look like they are brand new teeth; all a single color with perfect cusps, fossae and contours. Onlays can close spaces between teeth, where food gets impacted, they can also restore a brighter smile to mouths that have large amalgam (AKA: mercury) fillings.

Onlays are precision oriented; precision takes a bit of time, so expect your appointment to not be rushed and be done correctly the first time. Dr. Hoffman is a perfectionist when it comes to creating the proper onlay preparation.

This is because part of making an onlay look and feel correct involves a dental laboratory, who performs their work based on principles of material science. Onlay preparations must have certain reductions and shapes (AKA: Internal and external Morphology) in certain specific locations, which allow the materials to possess the proper strength to last the full life-expectancy, also for the shade and shape of the onlay to properly mimic a natural tooth.

Onlays do not get cavities, but the margin, or area where the onlay meets the tooth can get cavities. Actually, this area is the area that most commonly fails on an onlay tooth. There are two ways to combat this phenomenon: 1. Have the onlay fit correctly at the time of placement 2. Make sure proper flossing and brushing is done around the onlay nightly.

Onlays take 2 visits to complete. The first visit is the actual removal of the damage and/or cavities and the preparation of the tooth for the onlay. This is also where the impression is taken for the lab, and when your temporary onlay is fabricated. The second visit is to permanently deliver your new onlay; this visit only takes about 30-minutes or so. Before your new onlay is permanently delivered to you, all parties must be completely happy. You must be happy with the color (shade), shape and bite, and Dr. Hoffman must be happy with the x-ray, the margins, the interproximal contacts, and the bite. Once everyone thinks things are "perfect", Dr. Hoffman will ask your permission to permanently deliver your new onlay.

Halcion has a rather short half-life, about 4-hours, which makes it very good medicine for a dental environment, as most dental procedures are completed well within the lifespan of this medication.

Halcion should be taken 1-hour prior to your dental procedure, if prescribed to you by Dr. Hoffman. You may also request the use of Halcion for dental procedures. Dr. Hoffman will review the medication with you and recommend, or not recommend, its use based on your personal health history and medication review.

If you are prescribed Halcion for your dental visit(s), it is important to know a few things: you will need a driver to, and from, your appointment. We will not receive you for your appointment if you drive yourself, or arrive in a taxi/cab. You must have a driver than you know and trust, preferably a family member. Any/all consent forms for the procedure(s) that will be done at your appointment will need to be discussed and signed before that day, as the medicine will not allow you to sign medical-legal documents. All payment for procedure(s) that day must be paid-in-full before the day the procedure. We do not want you dealing with money or payments while under the influence of the Halcion medication. In summary, we want to take care of you on your appointment day, and have no worries/responsibilities on that day whatsoever.

While you are on the medication, you should expect to feel very comfortable, relaxed, and care-free. You may even fall asleep, and stay asleep for awhile, during your visit. This is perfectly acceptable, many times even helpful for everyone involved. Once you arrive, you will be walked into the dental chair from the lobby, walked back to the waiting room after the procedure; you will be even helped back to your waiting driver's car by our staff. Again, we will take care of everything while you are under the influence of this medication and in our office.

Halcion is becoming more-and-more popular with Dentists for short, to medium-length, dental procedures. This is due to the relative few contraindications and drug-drug interactions with this particular medication. Also, as stated above, the length of activity of this medication is ideal for most dental procedures.

If this medication sounds like something that might help you through your dental visit(s), please discuss this with Dr. Hoffman. Accommodations must be made in advance for the proper use of this medication. Below are some FDA facts about Halcion; if you would like to learn more, please visit their website.

Halcion Tablets contain triazolam, a triazolobenzodiazepine hypnotic agent. Triazolam is a white crystalline powder, soluble in alcohol and poorly soluble in water. It has a molecular weight of 343.21.The chemical name for triazolam is 8-chloro-6-(o-chlorophenyl)-1-methyl-4H-s-triazolo-[4,3-α] [1,4] benzodiazepine. The structural formula is represented below:

Contraindications

Halcion Tablets are contraindicated in patients with known hypersensitivity to this drug or other benzodiazepines.Benzodiazepines may cause fetal damage when administered during pregnancy. An increased risk of congenital malformations associated with the use of diazepam and chlordiazepoxide during the first trimester of pregnancy has been suggested in several studies. Transplacental distribution has resulted in neonatal CNS depression following the ingestion of therapeutic doses of a benzodiazepine hypnotic during the last weeks of pregnancy.

Halcion is contraindicated in pregnant women. If there is a likelihood of the patient becoming pregnant while receiving Halcion, she should be warned of the potential risk to the fetus. Patients should be instructed to discontinue the drug prior to becoming pregnant. The possibility that a woman of childbearing potential may be pregnant at the time of institution of therapy should be considered.Halcion is contraindicated with ketoconazole, itraconazole, and nefazodone, medications that significantly impair the oxidative metabolism mediated by cytochrome P450 3A

Warnings

Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of insomnia should be initiated only after a careful evaluation of the patient. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. Worsening of insomnia or the emergence of new thinking or behavior abnormalities may be the consequence of an unrecognized psychiatric or physical disorder. Such findings have emerged during the course of treatment with sedative-hypnotic drugs. Because some of the important adverse effects of sedative-hypnotics appear to be dose related (see Precautions and Dosage and Administration), it is important to use the smallest possible effective dose, especially in the elderly.

Complex behaviors such as "sleep-driving" (i.e., driving while not fully awake after ingestion of a sedative-hypnotic, with amnesia for the event) have been reported. These events can occur in sedative-hypnotic-naïve as well as in sedative-hypnotic-experienced persons. Although behaviors such as sleep-driving may occur with sedative-hypnotics alone at therapeutic doses, the use of alcohol and other CNS depressants with sedative-hypnotics appears to increase the risk of such behaviors, as does the use of sedative-hypnotics at doses exceeding the maximum recommended dose. Due to the risk to the patient and the community, discontinuation of sedative-hypnotics should be strongly considered for patients who report a "sleep-driving" episode.Other complex behaviors (e.g., preparing and eating food, making phone calls, or having sex) have been reported in patients who are not fully awake after taking a sedative-hypnotic. As with sleep-driving, patients usually do not remember these events.

Severe anaphylactic and anaphylactoid reactions

Rare cases of angioedema involving the tongue, glottis or larynx have been reported in patients after taking the first or subsequent doses of sedative-hypnotics, including Halcion. Some patients have had additional symptoms such as dyspnea, throat closing, or nausea and vomiting that suggest anaphylaxis. Some patients have required medical therapy in the emergency department. If angioedema involves the tongue, glottis or larynx, airway obstruction may occur and be fatal. Patients who develop angioedema after treatment with Halcion should not be rechallenged with the drug.

Central nervous system manifestations

An increase in daytime anxiety has been reported for Halcion after as few as 10 days of continuous use. In some patients this may be a manifestation of interdose withdrawal (see CLINICAL PHARMACOLOGY). If increased daytime anxiety is observed during treatment, discontinuation of treatment may be advisable.

A variety of abnormal thinking and behavior changes have been reported to occur in association with the use of benzodiazepine hypnotics including Halcion. Some of these changes may be characterized by decreased inhibition, eg, aggressiveness and extroversion that seem excessive, similar to that seen with alcohol and other CNS depressants (eg, sedative/hypnotics). Other kinds of behavioral changes have also been reported, for example, bizarre behavior, agitation, hallucinations, depersonalization. In primarily depressed patients, the worsening of depression, including suicidal thinking, has been reported in association with the use of benzodiazepines.

It can rarely be determined with certainty whether a particular instance of the abnormal behaviors listed above is drug induced, spontaneous in origin, or a result of an underlying psychiatric or physical disorder. Nonetheless, the emergence of any new behavioral sign or symptom of concern requires careful and immediate evaluation.

Because of its depressant CNS effects, patients receiving triazolam should be cautioned against engaging in hazardous occupations requiring complete mental alertness such as operating machinery or driving a motor vehicle. For the same reason, patients should be cautioned about the concomitant ingestion of alcohol and other CNS depressant drugs during treatment with Halcion Tablets.

As with some, but not all benzodiazepines, anterograde amnesia of varying severity and paradoxical reactions have been reported following therapeutic doses of Halcion. Data from several sources suggest that anterograde amnesia may occur at a higher rate with Halcion than with other benzodiazepine hypnotics.

The initial step in triazolam metabolism is hydroxylation catalyzed by cytochrome P450 3A (CYP 3A). Drugs that inhibit this metabolic pathway may have a profound effect on the clearance of triazolam. Consequently, triazolam should be avoided in patients receiving very potent inhibitors of CYP 3A. With drugs inhibiting CYP 3A to a lesser but still significant degree, triazolam should be used only with caution and consideration of appropriate dosage reduction. For some drugs, an interaction with triazolam has been quantified with clinical data; for other drugs, interactions are predicted from in vitro data and/or experience with similar drugs in the same pharmacologic class.

The following are examples of drugs known to inhibit the metabolism of triazolam and/or related benzodiazepines, presumably through inhibition of CYP 3A.

Potent CYP 3A inhibitors

Potent inhibitors of CYP 3A that should not be used concomitantly with triazolam include ketoconazole, itraconazole, and nefazodone. Although data concerning the effects of azole-type antifungal agents other than ketoconazole and itraconazole on triazolam metabolism are not available, they should be considered potent CYP 3A inhibitors, and their coadministration with triazolam is not recommended (see CONTRAINDICATIONS).

Drugs demonstrated to be CYP 3A inhibitors on the basis of clinical studies involving triazolam (caution and consideration of dose reduction are recommended during coadministration with triazolam)

Macrolide Antibiotics

Coadministration of erythromycin increased the maximum plasma concentration of triazolam by 46%, decreased clearance by 53%, and increased half-life by 35%; caution and consideration of appropriate triazolam dose reduction are recommended. Similar caution should be observed during coadministration with clarithromycin and other macrolide antibiotics.

Cimetidine

Coadministration of cimetidine increased the maximum plasma concentration of triazolam by 51%, decreased clearance by 55%, and increased half-life by 68%; caution and consideration of appropriate triazolam dose reduction are recommended.

Other drugs possibly affecting triazolam metabolism

Other drugs possibly affecting triazolam metabolism by inhibition of CYP 3A are discussed in the PRECAUTIONS section (see PRECAUTIONS–Drug Interactions).

Precautions

General

In elderly and/or debilitated patients it is recommended that treatment with Halcion Tablets be initiated at 0.125 mg to decrease the possibility of development of oversedation, dizziness, or impaired coordination.

Some side effects reported in association with the use of Halcion appear to be dose related. These include drowsiness, dizziness, light-headedness, and amnesia.The relationship between dose and what may be more serious behavioral phenomena is less certain. Specifically, some evidence, based on spontaneous marketing reports, suggests that confusion, bizarre or abnormal behavior, agitation, and hallucinations may also be dose related, but this evidence is inconclusive. In accordance with good medical practice it is recommended that therapy be initiated at the lowest effective dose (see DOSAGE AND ADMINISTRATION).

Cases of "traveler's amnesia" have been reported by individuals who have taken Halcion to induce sleep while traveling, such as during an airplane flight. In some of these cases, insufficient time was allowed for the sleep period prior to awakening and before beginning activity. Also, the concomitant use of alcohol may have been a factor in some cases.

Caution should be exercised if Halcion is prescribed to patients with signs or symptoms of depression that could be intensified by hypnotic drugs. Suicidal tendencies may be present in such patients and protective measures may be required. Intentional over-dosage is more common in these patients, and the least amount of drug that is feasible should be available to the patient at any one time.

The usual precautions should be observed in patients with impaired renal or hepatic function, chronic pulmonary insufficiency, and sleep apnea. In patients with compromised respiratory function, respiratory depression and apnea have been reported infrequently.

Information for patients

The text of a Medication Guide for patients is included at the end of this insert. To assure safe and effective use of Halcion, the information and instructions provided in this Medication Guide should be discussed with patients.

"Sleep-driving" and other complex behaviors

There have been reports of people getting out of bed after taking a sedative-hypnotic and driving their cars while not fully awake, often with no memory of the event. If a patient experiences such an episode, it should be reported to his or her doctor immediately, since "sleep-driving" can be dangerous. This behavior is more likely to occur when sedative-hypnotics are taken with alcohol or other central nervous system depressants (see WARNINGS). Other complex behaviors (e.g., preparing and eating food, making phone calls, or having sex) have been reported in patients who are not fully awake after taking a sedative hypnotic. As with sleep-driving, patients usually do not remember these events.

Laboratory tests

Laboratory tests are not ordinarily required in otherwise healthy patients.

Drug interactions

Both pharmacodynamic and pharmacokinetic interactions have been reported with benzodiazepines. In particular, triazolam produces additive CNS depressant effects when coadministered with other psychotropic medications, anticonvulsants, antihistamines, ethanol, and other drugs which themselves produce CNS depression.

Drugs that inhibit triazolam metabolism via cytochrome P450 3A

The initial step in triazolam metabolism is hydroxylation catalyzed by cytochrome P450 3A (CYP 3A). Drugs which inhibit this metabolic pathway may have a profound effect on the clearance of triazolam (see CONTRAINDICATIONS and WARNINGS for additional drugs of this type). Halcion is contraindicated with ketoconzaole, itraconazole, and nefazodone.

Drugs and other substances demonstrated to be CYP 3A inhibitors of possible clinical significance on the basis of clinical studies involving triazolam (caution is recommended during coadministration with triazolam)

Isoniazid

Coadministration of isoniazid increased the maximum plasma concentration of triazolam by 20%, decreased clearance by 42%, and increased half-life by 31%.

Oral contraceptives

Grapefruit juice

Coadministration of grapefruit juice increased the maximum plasma concentration of triazolam by 25%, increased the area under the concentration curve by 48%, and increased half-life by 18%.

Drugs demonstrated to be CYP 3A inhibitors on the basis of clinical studies involving benzodiazepines metabolized similarly to triazolam or on the basis of in vitro studies with triazolam or other benzodiazepines (caution is recommended during coadministration with triazolam)

Available data from clinical studies of benzodiazepines other than triazolam suggest a possible drug interaction with triazolam for the following: fluvoxamine, diltiazem, and verapamil. Data from in vitro studies of triazolam suggest a possible drug interaction with triazolam for the following: sertraline and paroxetine. Data from in vitro studies of benzodiazepines other than triazolam suggest a possible drug interaction with triazolam for the following: ergotamine, cyclosporine, amiodarone, nicardipine, and nifedipine. Caution is recommended during coadministration of any of these drugs with triazolam (see WARNINGS).

Drugs that affect triazolam pharmacokinetics by other mechanisms

Ranitidine

Coadministration of ranitidine increased the maximum plasma concentration of triazolam by 30%, increased the area under the concentration curve by 27%, and increased half-life by 3.3%. Caution is recommended during coadministration with triazolam.

Carcinogenesis, mutagenesis, impairment of fertility

No evidence of carcinogenic potential was observed in mice during a 24-month study with Halcion in doses up to 4,000 times the human dose.

Pregnancy

It is to be considered that the child born of a mother who is on benzodiazepines may be at some risk for withdrawal symptoms from the drug, during the postnatal period. Also, neonatal flaccidity has been reported in an infant born of a mother who had been receiving benzodiazepines.

Nursing mothers

Human studies have not been performed; however, studies in rats have indicated that Halcion and its metabolites are secreted in milk. Therefore, administration of Halcion to nursing mothers is not recommended.

Pediatric use

Safety and effectiveness of Halcion in individuals below 18 years of age have not been established.

Geriatric use

The elderly are especially susceptible to the dose related adverse effects of Halcion. They exhibit higher plasma triazolam concentrations due to reduced clearance of the drug as compared with younger subjects at the same dose. To minimize the possibility of development of oversedation, the smallest effective dose should be used (see CLINICAL PHARMACOLOGY, WARNINGS, PRECAUTIONS, and DOSAGE AND ADMINISTRATION).

Tolerance/Withdrawal Phenomena

Some loss of effectiveness or adaptation to the sleep inducing effects of these medications may develop after nightly use for more than a few weeks and there may be a degree of dependence that develops. For the benzodiazepine sleeping pills that are eliminated quickly from the body, a relative deficiency of the drug may occur at some point in the interval between each night's use. This can lead to (1) increased wakefulness during the last third of the night, and (2) the appearance of increased signs of daytime anxiety or nervousness. These two events have been reported in particular for Halcion.

There can be more severe 'withdrawal' effects when a benzodiazepine sleeping pill is stopped. Such effects can occur after discontinuing these drugs following use for only a week or two, but may be more common and more severe after longer periods of continuous use. One type of withdrawal phenomenon is the occurrence of what is known as 'rebound insomnia'. That is, on the first few nights after the drug is stopped, insomnia is actually worse than before the sleeping pill was given. Other withdrawal phenomena following abrupt stopping of benzodiazepine sleeping pills range from mild unpleasant feelings to a major withdrawal syndrome which may include abdominal and muscle cramps, vomiting, sweating, tremor, and rarely, convulsions.

Adverse Reactions

During placebo-controlled clinical studies in which 1,003 patients received Halcion Tablets, the most troublesome side effects were extensions of the pharmacologic activity of triazolam, eg, drowsiness, dizziness, or light-headedness.

The figures cited below are estimates of untoward clinical event incidence among subjects who participated in the relatively short duration (i.e., 1 to 42 days) placebo-controlled clinical trials of Halcion. The figures cannot be used to predict precisely the incidence of untoward events in the course of usual medical practice where patient characteristics and other factors often differ from those in clinical trials. These figures cannot be compared with those obtained from other clinical studies involving related drug products and placebo, as each group of drug trials is conducted under a different set of conditions.

Comparison of the cited figures, however, can provide the prescriber with some basis for estimating the relative contributions of drug and nondrug factors to the untoward event incidence rate in the population studied. Even this use must be approached cautiously, as a drug may relieve a symptom in one patient while inducing it in others. (For example, an anticholinergic, anxiolytic drug may relieve dry mouth [a sign of anxiety] in some subjects but induce it [an untoward event] in others.)

In addition to these untoward events for which estimates of incidence are available, the following adverse events have been reported in association with the use of Halcion and other benzodiazepines: amnestic symptoms (anterograde amnesia with appropriate or inappropriate behavior), confusional states (disorientation, derealization, depersonalization, and/or clouding of consciousness), dystonia, anorexia, fatigue, sedation, slurred speech, jaundice, pruritus, dysarthria, changes in libido, menstrual irregularities, incontinence, and urinary retention. Other factors may contribute to some of these reactions, eg, concomitant intake of alcohol or other drugs, sleep deprivation, an abnormal premorbid state, etc.

Other events reported include: paradoxical reactions such as stimulation, mania, an agitational state (restlessness, irritability, and excitation), increased muscle spasticity, sleep disturbances, hallucinations, delusions, aggressiveness, falling, somnambulism, syncope, inappropriate behavior and other adverse behavioral effects. Should these occur, use of the drug should be discontinued.The following events have also been reported: chest pain, burning tongue/glossitis/stomatitis.

Laboratory analyses were performed on all patients participating in the clinical program for Halcion. The following incidences of abnormalities were observed in patients receiving Halcion and the corresponding placebo group. None of these changes were considered to be of physiological significance.

Overdosage

Because of the potency of triazolam, some manifestations of overdosage may occur at 2 mg, four times the maximum recommended therapeutic dose (0.5 mg).Manifestations of overdosage with Halcion Tablets include somnolence, confusion, impaired coordination, slurred speech, and ultimately, coma. Respiratory depression and apnea have been reported with overdosages of Halcion. Seizures have occasionally been reported after overdosages.

Death has been reported in association with overdoses of triazolam by itself, as it has with other benzodiazepines. In addition, fatalities have been reported in patients who have overdosed with a combination of a single benzodiazepine, including triazolam, and alcohol; benzodiazepine and alcohol levels seen in some of these cases have been lower than those usually associated with reports of fatality with either substance alone.

As in all cases of drug overdosage, respiration, pulse, and blood pressure should be monitored and supported by general measures when necessary. Immediate gastric lavage should be performed. An adequate airway should be maintained. Intravenous fluids may be administered.

Flumazenil, a specific benzodiazepine receptor antagonist, is indicated for the complete or partial reversal of the sedative effects of benzodiazepines and may be used in situations when an overdose with a benzodiazepine is known or suspected. Prior to the administration of flumazenil, necessary measures should be instituted to secure airway, ventilation and intravenous access. Flumazenil is intended as an adjunct to, not as a substitute for, proper management of benzodiazepine overdose. Patients treated with flumazenil should be monitored for resedation, respiratory depression, and other residual benzodiazepine effects for an appropriate period after treatment. The prescriber should be aware of a risk of seizure in association with flumazenil treatment, particularly in long-term benzodiazepine users and in cyclic antidepressant overdose.

Halcion Dosage and Administration

It is important to individualize the dosage of Halcion Tablets for maximum beneficial effect and to help avoid significant adverse effects.

The recommended dose for most adults is 0.25 mg before retiring. A dose of 0.125 mg may be found to be sufficient for some patients (e.g., low body weight). A dose of 0.5 mg should be used only for exceptional patients who do not respond adequately to a trial of a lower dose since the risk of several adverse reactions increases with the size of the dose administered. A dose of 0.5 mg should not be exceeded.

In geriatric and/or debilitated patients the recommended dosage range is 0.125 mg to 0.25 mg. Therapy should be initiated at 0.125 mg in these groups and the 0.25 mg dose should be used only for exceptional patients who do not respond to a trial of the lower dose. A dose of 0.25 mg should not be exceeded in these patients.As with all medications, the lowest effective dose should be used.

MEDICATION GUIDEHalcion Tablets/ C-IV

Read this Medication Guide before you start taking Halcion and each time you get a refill. There may be new information. This Medication Guide does not take the place of talking to your doctor about your medical condition or treatment. You and your doctor should talk about the SEDATIVE-HYPNOTIC when you start taking it and at regular checkups.

What is the most important information I should know about Halcion?

After taking a SEDATIVE-HYPNOTIC, you may get up out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night. You have a higher chance for doing these activities if you drink alcohol or take other medicines that make you sleepy with a SEDATIVE-HYPNOTIC. Reported activities include:

• driving a car ("sleep-driving")• making and eating food• talking on the phone• having sex• sleep-walking

Important:

1.Take Halcion exactly as prescribed

• Do not take more Halcion than prescribed.• Take Halcion right before you get in bed, not sooner.

2.Do not take Halcion if you:• drink alcohol• take other medicines that can make you sleepy. Talk to your doctor about all of your medicines. Your doctor will tell you if you can take Halcion with your other medicines• cannot get a full night's sleep• are pregnant or considering becoming pregnant

3.Call your doctor right away if you find out that you have done any of the above activities after taking Halcion.

What are SEDATIVE-HYPNOTICS?

SEDATIVE-HYPNOTICs are sleep medicines. SEDATIVE-HYPNOTICS are used in adults for the treatment of the symptom of trouble falling asleep due to insomnia.Halcion is not indicated for use in children.

Halcion is a federally controlled substance (C-IV) because it can be abused or lead to dependence. Keep Halcion in a safe place to prevent misuse and abuse. Selling or giving away Halcion may harm others, and is against the law. Tell your doctor if you have ever abused or been dependent on alcohol, prescription medicines or street drugs.Who should not take Halcion?

Do not take Halcion if you are allergic to anything in it. See the end of this Medication Guide for a complete list of ingredients in Halcion.

SEDATIVE-HYPNOTICS may not be right for you. Before starting SEDATIVE-HYPNOTICS, tell your doctor about all of your health conditions, including if you:

• have a history of depression, mental illness, or suicidal thoughts• have a history of drug or alcohol abuse or addiction• have kidney or liver disease• have a lung disease or breathing problems• are pregnant, planning to become pregnant, or breastfeeding

Tell your doctor about all of the medicines you take including prescription and nonprescription medicines, vitamins and herbal supplements. Medicines can interact, sometimes causing side effects. Do not take SEDATIVE-HYPNOTICS with other medicines that can make you sleepy.

Know the medicines you take. Keep a list of your medicines with you to show your doctor and pharmacist each time you get a new medicine.

Halcion should not be taken with potent inhibitors of CYP 3A including ketoconazole, itraconazole, nefazodone and possibly other azole-type antifungal agents.

How should I take Halcion?

• Take Halcion exactly as prescribed. Do not take more Halcion than prescribed for you.• Take Halcion right before you get into bed. Or you can take the Halcion after you have been in bed and have trouble falling asleep.• Do not take Halcion with or right after a meal.• Do not take Halcion unless you are able to get a full night's sleep before you must be active again.• Call your healthcare provider if your insomnia worsens or is not better within 7 to 10 days. This may mean that there is another condition causing your sleep problem.• If you take too much Halcion or overdose, call your doctor or poison control center right away, or get emergency treatment.

What are the possible side effects of SEDATIVE-HYPNOTICS?

Serious side effects of SEDATIVE-HYPNOTICS include:

• getting out of bed while not being fully awake and doing an activity that you do not know you are doing. (See "What is the most important information I should know about SEDATIVE-HYPNOTICS?)• abnormal thoughts and behavior. Symptoms include more outgoing or aggressive behavior than normal, confusion, agitation, hallucinations, worsening of depression, and suicidal thoughts or actions.• memory loss, including "traveler's amnesia"• anxiety• severe allergic reactions. Symptoms include swelling of the tongue or throat, trouble breathing, and nausea and vomiting. Get emergency medical help if you get these symptoms after taking

SEDATIVE-HYPNOTICS.

Call your doctor right away if you have any of the above side effects or any other side effects that worry you while using the SEDATIVE-HYPNOTIC.Common side effects of Halcion include:• drowsiness• headache• dizziness• lightheadedness• "pins and needles" feelings on your skin• difficulty with coordination• You may still feel drowsy the next day after taking Halcion. Do not drive or do other dangerous activities (including operating machinery) after taking Halcion until you feel fully awake.• You may have withdrawal symptoms for 1 to 2 days when you stop taking the SEDATIVE-HYPNOTIC suddenly. Withdrawal symptoms include trouble sleeping, unpleasant feelings, stomach and muscle cramps, vomiting, sweating, shakiness, and seizures.

These are not all the side effects of SEDATIVE-HYPNOTICS. Ask your doctor or pharmacist for more information.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Today's fillings are tooth-colored, composite material that is condensed inside the area(s) of a tooth which used to be a cavity, or a previous filling.

Composite Replacements

Once finished and hardened with a special dental curing light, the fillings are ready to be shaped and polished. When a patient leaves the office, this type of composite filling is as hard as they are going to get and, after the anesthesia has worn-off, the patient can eat on them immediately, without concern for fracture or breakage.

Fillings are terrific restoration for small, moderate, and sometimes even moderate-to-severe sized cavities, or fractures, depending on where the damage is located in the tooth.

These composite fillings actually "bond" to the tooth through a mechanism known as micromechanical retention. This is accomplished by the use of an acid gel on your teeth, which slightly demineralizes the area the filling will be placed.

This provides thousands, to tens-of-thousands, of small nooks-and-crannies for the composite material to attach to both chemically and mechanically.

Other substances called primers and bonding agents are used to provide the chemical attachment, which allows each subsequent layer of material to actually chemically attach to the tooth, then to the next level material. It's quite amazing actually, and looks terrific, while lasting as long as the previous amalgam fillings (AKA: Mercury fillings). There is no mercury in these new fillings, just all space-age materials that are in use today in many industries, including the aerospace industry.

These composite fillings are technique sensitive, much more so than amalgam fillings, so they must be placed in a very exacting way. Any saliva, or water, that comes in contact with the fillings as they are being placed will cause them to fail prematurely; this is called contamination. So, the Dentist will probably place a rubber dam, or a large amount of cotton rolls, into your mouth when performing this procedure. This is normal, and necessary for a good outcome. Once the curing light has been used on the filling material it is watertight and safe for use in the mouth.

A Root Canal is a microsurgery, where the nerve and the blood supply of a tooth is amputated and removed, the canals that previously held the nerves and blood vessels are shaped properly with a series of endodontic files, then those newly cleaned and shaped canals are disinfected with a series of medicinal rinses.

Finally, the ideally shaped canals are dried and a rubber-type material called Gutta Percha is used to obturate, or seal, the canals from re-contamination.

In order to access the pulp chamber of the tooth, a small hole will be made directly in the center of your tooth's crown. The access can be made either through an existing prosthetic crown, or "cap", or will be done directly through your natural tooth. Once the root canal is completed, there will either be a temporary filling placed into the accessed area, or a final build-up will be placed.

While it is perfectly acceptable, and even sometimes advantageous, to access the pulp chamber and canals through an existing prosthodontic crown, or "cap", it should be understood that crown has now been compromised, and should be replaced in approximately 30-days from the date of the root canal. Leakage, or contamination, is almost assured in these types of access situations. Since a root canal is not a cheap procedure, due to the level of difficulty and skill required to perform these procedures correctly, it is highly advisable to protect that investment with a new build-up and a new crown, to properly seal the root canal and tooth. This will guarantee the longest life expectancy for your root canal, and tooth overall, increasing the prognosis.

Root canals do not hurt while being performed.

Local anesthesia is given to put your tooth to "sleep". Patients many times state "It feels as if you are working on someone else's mouth." In fact, we have had many patients who actually fall completely asleep while we are performing the procedure and have to wake them up, in order to have them move their head for the Doctor. At patient request, and at Dr. Hoffman's discretion, medications may be indicated to keep anxious or fearful patients comfortable. If interested, please inquire about this option, as it is not routine, but easily accommodated, in most cases.

After the root canal is completed and the anesthesia has worn-off, there may be SLIGHT discomfort...not pain. The possibility of discomfort does come from the nature of microsurgery being performed, and the nerve and blood supply being amputated. This discomfort, if measured on a scale of 0-10, with 0 being asleep and 10 being the worst pain imaginable; most patients report discomfort from a level of 0-3, that may last for up to 48-72 hours maximum. Most patients will receive NSAIDs immediately after treatment to keep discomfort extremely tolerable, to non-noticeable, provided you medical history allows these medicines.

A crown is a full-coverage prosthetic tooth replacement. It is not an implant; it does not replace the root(s) of a tooth, just the portion above the gumline. Crowns are recommended when teeth are severely damaged, malformed, or have had a root canal procedure.

Crowns look exactly like real teeth, in many cases even better, as they look like they are brand new teeth; all a single color of your choosing, with perfect cusps, fossae and contours.

Crowns can close spaces between teeth, where food gets impacted, they can also restore a brighter smile to mouths that have large amalgam (AKA: mercury) fillings. Also, if placed together to form a bridge, can replace entire missing teeth making an entire segment of a mouth look and function like it did when you were younger.

Crowns require precision; precision takes a bit of time, so expect your appointment to not be rushed and be done correctly the first time.

Dr. Hoffman is a perfectionist when it comes to creating the proper crown preparation. This is because part of making a crown look and feel correct involves a dental laboratory, who performs their work based on principles of material science.

Crown preparations must have certain reductions, in certain locations, to allow the materials to possess the proper strength to last the full life-expectancy, also for the shade and shape of the crown to properly mimic a natural tooth. If a tooth is having a crown for the first time, and the damage is not overly severe, a crown should last between 15-30 years.

Crowns do not get cavities, but the margin, or area where the crown meets the tooth can get cavities. Actually, this area is the area that most commonly fails on a crowned tooth. There are two ways to combat this phenomenon: 1. Have the crown fit correctly at the time of placement 2. Make sure proper flossing and brushing is done around the crown nightly.

Crowns take 2 visits to complete. The first visit is the actual removal of the damage and/or cavities, the rebuilding of the tooth, and the preparation of the tooth for the crown. This is also where the impression is taken for the lab, and when your temporary crown is fabricated.

The second visit is to permanently deliver your new crown; this visit only takes about 30-minutes or so. Before your new crown is permanently delivered to you, all parties must be completely happy. You must be happy with the color (shade), shape and bite, and Dr. Hoffman must be happy with the x-ray, the margins, the interproximal contacts, and the bite. Once everyone thinks things are "perfect", Dr. Hoffman will ask your permission to permanently deliver your new crown.